PURPOSE:To evaluate the interobserver agreement of chest computed tomography (CT) findings in the diagnosis of expected changes and local recurrence after stereotactic body radiation therapy (SBRT) in patients with early-stage lung cancer or a single pulmonary metastasis.MATERIALS AND METHODS:A total of 54 patients with early-stage lung cancer or pulmonary metastasis who were treated with SBRT from 2007 to 2015 were included. The exclusion criteria were patients who presented with pulmonary infection during follow-up and patients who underwent a single CT during follow-up. The imaging features on CT were assessed by 3 blinded radiologists at the following 2 time points after SBRT: (a) early follow-up and (b) late follow-up (≥6 mo). The radiologists classified the findings as expected changes after SBRT or recurrence. Interobserver agreement was assessed by kappa and Wilcoxon statistics.RESULTS:A total of 13 women and 41 men with a mean age of 75.3 (±8.9) years were selected. The total and per fraction SBRT doses were 54 Gy (interquartile range: 45 to 54) and 18 Gy (interquartile range: 15 to 18), respectively. All expected changes and findings suggestive of recurrence had an almost perfect agreement (κ>0.85) among readers, except for diffuse consolidation in the early period (κ=0.65).CONCLUSION:CT findings demonstrate high interobserver agreement for expected changes and for findings indicating recurrence after SBRT.

Abstract Background The aim of this study was to evaluate the correlation between clinical and imaging findings with a worse clinical outcome in patients with a confirmed diagnosis of H1N1 influenza A virus. Methods Patients with a positive viral test for influenza A H1N1 in 2016 and chest radiography (CR) and/or computed tomography (CT) results had clinical and imaging data reviewed. Hospitalization, admission to the intensive care unit or death were defined as worse clinical outcomes. The association between clinical and imaging features and the worse outcome was calculated in a logistical regression model. Results Eighty of 160 (50%) patients were men, with a mean age of 43 ± 19 years. The most common symptoms were as follows: flu-like symptoms 141/160 (88%), dyspnea (25/160, 17%), and thoracic pain (7/160, 5%). Abnormalities on CR were detected in 8/110 (7%) patients, and 43/59 (73%) patients had an abnormal CT. The following variables were associated with worse clinical outcomes: the presence of diabetes mellitus (DM), hypertension, dyspnea, thoracic pain, abnormal CR or CT regardless of the type of finding, CT with consolidation or ground glass opacity. Conclusions The presence of DM, hypertension, dyspnea, thoracic pain, or an abnormal CR or CT on admission were associated with worse clinical outcomes in patients with H1N1 influenza A virus infection. Thus, the use of readily accessible clinical and imaging features on admission may have a role in the evaluation of patients with H1N1 infection.

1. Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brazil. 2. Hospital Casa de Portugal – 3D Diagnose, Rio de Janeiro, RJ, Brazil. 3. Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Mailing address: Dr. Bruno Niemeyer de Freitas Ribeiro. Instituto Estadual do Cérebro Paulo Niemeyer – Departamento de Radiologia. Rua do Rezende, 156, Centro. Rio de Janeiro, RJ, Brazil, 20231-092. E-mail: bruno.niemeyer@hotmail.com. The frequency of metastases to the skin is rare, ranging from 0.7% to 9%, such metastases occurring mainly in advanced-stage lung and breast cancers, predominantly affecting the scalp, neck, forearm, thigh, or penis. To our knowledge, there have been no studies discussing the imaging characteristics of squamous cell carcinoma metastases to the skin. In the case presented here, the lesions were similar to the primary tumor, with hypointense signals in T1-weighted sequences and isointense or hypointense signals in T2-weighted sequences, as well as heterogeneous gadolinium enhancement and restricted diffusion. Recent studies highlight the use of diffusion-weighted sequences in the evaluation of head and neck lesions, showing that apparent diffusion coefficient values below 1.22 × 10 mm/s are suggestive of malignancy. In our case, the apparent diffusion coefficient value was 0.78 × 10 mm/s, thus corroborating those previous findings. The differential diagnosis of cutaneous lesions is extensive, including hemangiomas, pilomatrixomas, tuberculosis, leishmaniasis, lymphomas, and sarcomas. Although imaging methods can help in distinguishing among the causes, the diagnosis in typically made through histopathological analysis. Cutaneous metastases are uncommon and do not present specific imaging characteristics. They should nevertheless be considered among the diagnostic possibilities in cases of cutaneous lesions, particularly when there is a known history of neoplasia. REFERENCES

OBJECTIVE. The objectives of the present study were to estimate the frequency of epipericardial fat necrosis among patients undergoing chest CT for chest pain and to compare the clinical and laboratory data between patients with epipericardial fat necrosis and control subjects.MATERIALS AND METHODS. A retrospective review of 7463 chest CT studies performed in the emergency department from July 2011 to December 2014 was conducted to collect data regarding patient demographic characteristics and CT findings. Twenty patients who had epipericardial fat necrosis diagnosed were defined as the main patient group. An age- and sex-matched control group was selected from patients with chest pain who underwent chest CT during the same period. Linear regression models were used to assess data, and statistical significance was expressed as p values and 95% CIs.RESULTS. We found that the frequency of epipericardial fat necrosis was 2.15% among patients who underwent chest CT for chest pain. Epipericardial fat necrosis was statistically significantly associated with a lack of medication use (p = 0.01; 95% CI, -3.33 to -0.40) and the absence of other symptoms (p = 0.005; 95% CI, -5.83 to -1.27). Epipericardial fat necrosis was most often observed as an ovoid lesion with mixed fat attenuation with little stranding in the left paracardiac region accompanied by pleural effusion.CONCLUSION. Epipericardial fat necrosis is a significant clinical condition. For patients seen in the emergency department with isolated acute chest pain but no additional clinical history, no medication history, and normal laboratory results, chest CT is recommended to support a diagnosis of epipericardial fat necrosis.

OBJECTIVE:The aims of this study were to define imaging findings and to identify any predisposing factors for the development of the round lytic lesion across the margins of sternotomy during the process of bone healing.METHODS:We searched all chest CT scans performed between 2007 and 2012 and selected patients who had three studies performed in the recent, late and latest post-operative periods. Patients presenting any complications related to wound healing were excluded from the study. CT features of the sternotomy and possible instability factors were assessed.RESULTS:From 15689 chest CT images analysed, 68 patients fulfilled the criteria. The development of a round lytic lesion was observed in 35 and 39 patients in the late and latest post-operative periods, respectively, and there was an association between mild misalignment of margins in the recent post-operative period and the development of a round lesion in the follow-up periods (p=0.010 and p=0.002, respectively).CONCLUSION:Sternotomies exhibit a delayed and unusual pattern of bone healing, and minimal instability factors during bone closure could trigger the development of a lytic lesion that is part of the normal healing process.ADVANCES IN KNOWLEDGE:This lytic bone lesion is part of the bone healing, and its appearance should not be mistaken as infection or malignancy, even in a suggestive clinical setting.

Objective: Epipericardial fat necrosis (EFN) is an uncommon benign and self-limited condition that leads patients to the emergency department (ED) owing to the onset of acute pleuritic chest pain. The aim of this study was to describe the cases of this disease in our institution and to illustrate the associated clinical and radiological findings.Methods: We reviewed 3604 chest scans referred by the ED from November 2011 to July 2013. Patients diagnosed with epipericardial necrosis had their medical records and original tomography reports analysed.Results: Chest pain was the primary complaint in 426 patients; 11 of them had definitive EFN findings characterized by a round soft-tissue attenuation lesion with a varying degree of strands. All patients presented with pleuritic chest pain on the same side as the lesion. Pericardial thickening, pleural effusion and mild atelectasis were the associated tomography findings. Cardiac enzyme and D-dimer tests performed during the episode were normal in all cases. 27% of the cases only were correctly diagnosed with EFN at the time of presentation.Conclusion: EFN is a benign inflammatory condition frequently overlooked in the ED by physicians and radiologists but is an important factor in the differential diagnosis of patients with acute chest pain.Advances in knowledge: The article adds clinically and radiologically useful information about the condition and displays the importance of making the correct diagnosis to avoid unnecessary examinations.

BACKGROUND:Toxoplasmosis is one of the most common human zoonosis, and is generally benign in most of the individuals. Pulmonary involvement is common in immunocompromised subjects, but very rare in immunocompetents and there are scarce reports of tomographic findings in the literature. The aim of the study is to describe three immunocompetent patients diagnosed with acute pulmonary toxoplasmosis and their respective thoracic tomographic findings. Acute toxoplasmosis was diagnosed according to the results of serological tests suggestive of recent primary infection and the absence of an alternative etiology.CASE PRESENTATION:From 2009 to 2013, three patients were diagnosed with acute respiratory failure secondary to acute toxoplasmosis. The patients were two female and one male, and were 38, 56 and 36 years old. Similarly they presented a two-week febrile illness and progressive dyspnea before admission. Laboratory tests demonstrated lymphocytosis, slight changes in liver enzymes and high inflammatory markers. Tomographic findings were bilateral smooth septal and peribronchovascular thickening (100%), ground-glass opacities (100%), atelectasis (33%), random nodules (33%), lymph node enlargement (33%) and pleural effusion (66%). All the patients improved their symptoms after treatment, and complete resolution of tomographic findings were found in the followup.CONCLUSION:These cases provide a unique description of the presentation and evolution of pulmonary tomographic manifestations of toxoplasmosis in immunocompetent patients. Toxoplasma pneumonia manifests with fever, dyspnea and a non-productive cough that may result in respiratory failure. In animal models, changes were described as interstitial pneumonitis with focal infiltrates of neutrophils that can finally evolve into a pattern of diffuse alveolar damage with focal necrosis. The tomographic findings are characterized as ground glass opacities, smooth septal and marked peribronchovascular thickening; and may mimic pulmonary congestion, lymphangitis, atypical pneumonia and pneumocystosis. This is the largest series of CT findings of acute toxoplasmosis in immunocompetent hosts, and the diagnosis should be considered as patients that present with acute respiratory failure in the context of a subacute febrile illness with bilateral and diffuse interstitial infiltrates with marked peribronchovascular thickening. If promptly treated, pulmonary toxoplasmosis can result in complete clinical and radiological recovery in immunocompetent hosts.

Pseudocistos pulmonares são lesões raras que se desenvolvem no parênquima pulmonar após traumas fechados e de grande energia, cujo diagnóstico se baseia na associação da história clínica com exames de imagem. Relata-se a seguir um pseudocisto pulmonar ocorrido no parênquima contralateral ao trauma em um homem de 31 anos que apresentou episódio de hemoptise após queda durante partida de futebol.

Pulmonary pseudocysts are uncommon cavitary lesions that develop in the lung parenchyma as a consequence of blunt thoracic trauma, whose diagnosis is based on an association of clinical history and imaging findings. The present report describes the case of a pulmonary pseudocyst observed in the parenchyma contralateral to the trauma site in a 31year-old man presenting with hemoptysis after falling during a soccer match.

Epipericardial fat necrosis is a rare, benign, and self-limited cause of acute chest pain, with only 35 cases reported in the literature.(1,2) It presents as new-onset pleuritic chest pain in otherwise healthy patients, and, therefore, it is an important differential diagnosis for acute chest pain in this group of individuals. The pathophysiology has been labeled as idiopathic or related to an acute damage of this fat tissue secondary to vascular torsion, trauma, or microvascular bleeding.